THE
STANDARD
(none)
Volume 5, No. 2
Maintaining Regularity:
Constipation, Fiber and Natural Laxatives
Thomas G. Guilliams Ph.D.
"The civilized colon is a poor cripple, maimed, misshapen, overstretched in parts,
contracted in other parts, prolapsed, adherent, "kinked", infected, paralyzed, inefficient,
incompetent. It is the worst abused and the most variously damaged of any organ of the
body... The civilized colon... is a Golgotha of pollution, a veritable Pandora's box of
disease."
John Harvey Kellogg, 1918 (1)
Perhaps before any other disease was labeled as being the result of civilization,
constipation and its presumed consequences were bill boarded as the quintessential disease of
civilized, urbanized, and sedentary men... and women. Many considered it to be the root of
all diseases, and treatment options have been varied and numerous. In this review, we hope to
show the relationship between constipation and other conditions with which it is related,
either as a consequence or causative factor. We will focus primarily on the various natural
ingredients that have been used to treat constipation and the additional benefits of
dietary fiber.
Perhaps defining constipation is nearly as difficult as defining "normal" stool frequency.
Disagreement on what constitutes "normal" is well established when asking various health care
providers and even more varied when asking patients. Most would agree that stool frequency
less than 3 times per week would define constipation, although many would say that less than
once per day may constitute constipation. In addition to frequency, difficult evacuation of
hard, dry stools may constitute the diagnosis of constipation. Regardless of how constipation
is defined, we should remember that constipation is a symptom, not a disease. The underlying
causes of constipation may be quite varied and therefore treatment protocols vary as well.
Causes may include endocrine disorders such as diabetes and hypothyroidism, neurological
diseases such as MS, Parkinson's or spinal cord injuries, or diseases within the colon/anal
area like anal fissures or inflammatory bowel disease. Many drug and surgery interventions
will also lead to symptoms of constipation. The primary cause, however, is the diet and
lifestyle factors that are common in the American culture.
Maintaining regularity is almost a non-issue for those without constipation, but for those
who suffer from it (or think they do) it is an all consuming passion. Historically,
constipation has always been high on the list of symptoms which patients self diagnose and
self treat. Over-the-counter (OTC) remedies have been sold and marketed as long as anyone can
remember. In fact, the concern over constipation may have been the greatest impetus for the
breakfast cereal industry in the early 1900's.
Because of the issue of definition, it has always been difficult to study constipation in the
general population. What we have learned is that women, especially petite women within child-
bearing age, seem to be the population most afflicted with constipation (2). One way to get
general information may be through laxative use. However estimates of laxative use (which
have been estimated at 10% of the U.S. population) may not be an adequate way to assess
populations as patients concerned about constipation are prone to underestimate bowel
frequency and overuse laxatives (3). This is why physicians need to take an extensive patient
history when assessing the patient's bowel issues. Questions should include what they
consider "normal", how long they have been constipated, and what remedies have they tried and
when. A stool diary which includes time, difficulty in passing, general appearance and size
of stool should be considered along with a food and water diary.
Connecting constipation with lifestyle factors has been problematic, at least in the
published research. While constipation has been shown to be related to inactivity, no
conclusive evidence exists for a positive effect of physical exercise as a treatment option
for chronic constipation (4,5). In one recent study from Japan, exercise (walking), as
well
as dietary fiber intake (from rice), were significant in reducing the risk of constipation
(6). Allergy/intolerance to cow's milk protein has been shown to be linked to chronic
constipation in some children (7). The role diet plays in constipation is covered in the Diet
and Lifestyle section below.
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Constipation as a risk factor
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It is always difficult to make epidemiological connections with something as general as
constipation, but several promising connections have been made. It is known that bowel
transit time effects the microbial environment of the colon. The colon is populated by
numerous beneficial microorganisms which help digestion and protect against disease (For a
review see The Standard Vol. 2 No. 2). When bowel transit time is increased or decreased
experimentally in subjects with constant diet, dramatic changes in overall stool weight and
character are observed, along with dramatic changes in microbial mass. Slowing bowel transit
time decreases the numbers of helpful microbial organisms in the bowel, and this may increase
susceptibility to disease (8). This was shown to be the case in Japanese children during a
outbreak of Escherichia coli 0157 in 1996. Those children with fewer bowel movements were
much more likely to have severe symptoms to the E.coli, than those children with bowel
movements on a daily basis (9). These data suggest that the addition of probiotic therapy for
patients experiencing constipation will likely prove beneficial.
Slow bowel transit time is also associated with increased deoxycholic acid (DCA) in the bile,
which increases the risk of gallstone formation (10). Measuring biliary DCA, as well as
laxative use, is predictive for recurrence of gallstone formation (11). Likewise, in some
studies, dietary fiber is protective against gallstone formation (11,12 -in animal
model).
Constipation also is strongly associated with gallbladder and bile duct cancers (13),
especially in cases of previous gallbladder problems. Chronic constipation (linked to lower
fiber intake) is also statistically related to increased risk of appendicitis in children
(14).
Previously it was noted that patients with Parkinson's disease (PD) often have associated
constipation. In a very interesting epidemiological study it was discovered that constipation
may actually be part of early PD processes, a marker of susceptibility or an environmental
factor that may cause PD (15). A follow-up of 6,790 men in the Honolulu Heart Program during
a 24 year period revealed that men with less than one bowel movement per day were 2.7 times
more likely to have PD than those with at least 1/day. And the risk was 4.5 times higher than
men with more than two bowel movements per day.
The role of constipation, laxative use, or both, has been controversial in the increased risk
of colorectal cancer. Epidemiological studies have shown a relationship between repeated
bouts of constipation and colon cancer (16,17). Laxative use is associated with the
constipation, but usually not implicated as causative. The relationship is likely related to
decreased levels of beneficial microorganisms, stress on the colon wall and a diet that
promotes both cancer and constipation (18). A diet high in protective phytonutrients is
usually also accompanied with adequate dietary fiber to promote bowel regularity. Conversely,
diets high in cooked fat and meats, with little fruits and vegetables, provides little fiber
and are laden with cancer promoting hydrocarbons (19).
Of course for many, the largest issue concerning constipation is what is referred to as
autointoxication, or systemic toxemia. Generally this is defined as a prolongation of toxins
in the colon, allowing ample time for them to enter back into the blood stream and stress the
liver as well as other organ systems, and lead to disease. This, many say, is the real
potential danger of slow bowel transit times. This is not a trivial subject because, in one
sense, this was the impetus for the beginning of the discipline of naturopathic medicine.
This subject, however, is much too large and complex to be covered in this review and the
reader is directed to the texts in the "General" section of the references.
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Diet and Lifestyle are key
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While there are many therapies one could use, we will deal primarily with those related to
diet and dietary supplements. It is important to note that the general information here is
largely for idiopathic (primarily lifestyle
induced) constipation caused by lack of "tone" (atonic). These recommendations are not for
the less common spastic constipation, which will not be covered in this review.
"One of the gravest defects of the civilized diet is its lack of raw foods and ballast, or
roughage. We eat over-milled cereals, chemicalised sugars, softly cooked vegetables, sloppy
seasoned hashes, slushy puddings and soups, pappy porridges, sophisticated and highly-refined
concocted dished of all kinds. In such a diet there are no rough irritating substances to
stimulate intestinal peristalsis."
George Dupain, 1934 (20)
It would be difficult to overestimate the role diet, specifically dietary fiber intake, is
thought to play in the cause of constipation in Western countries. Comparing dietary fiber
intake between populations has often correlated positively with stool frequency and weight
and inversely with colon diseases including cancer. Likewise, the increase in refinement of
sugars and carbohydrates is linked with slowing bowel transit times and altering the
environment of the colon (21). Perhaps the poster child for the movement against refined
foods and their lack of health benefits was, and maybe still is, white bread. As Arbuthnot
Lane had said on one occasion "the whiter your bread, the sooner you're dead". White bread,
it has been said, embodies the very misuse of the technologies available to us, which allowed
us to easily remove health benefits from the "staff of life" for the sake of convenience and
profit.
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Fiber - An essential component
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Just like vitamins and minerals, dietary fiber has a daily recommended value (DRV). The
current DRV for dietary fiber is 25 grams per day, but many believe this is much too low to
maintain optimal health and should be closer to 40 or even 50 grams per day. But even at
these lower levels, most Americans are not getting adequate levels of dietary fiber according
to the American Dietetic Association (22). In children, recommendations are typically
determined by adding 5 to the child's age to get the recommended grams per day (child age 7 =
12 grams/day). But how does one define dietary fiber.
Dietary fiber can be technically described as all plant non-starch polysaccharides, with the
addition of plant lignins. This includes celluloses, gums, pectins, and mucilages. Plant
fiber is nearly indigestible in humans and is often referred to as "roughage". Most dietary
fiber is found in fruits, vegetables, legumes and grains. Some standard foods are found in
Table 1, along with their typical fiber content. As the table shows, dietary fiber can be
further divided into soluble and insoluble fiber. This characteristic does not mean true
solubility (in the chemical sense), but describes those fibers which are dispersible in
water. The soluble fibers, such as pectin and gums have a very high water holding capacity
and often form a gel when mixed with water. Insoluble fibers hold very little water and will
usually fall to the bottom of a glass when mixed in water. Most non-isolated plant fibers
(eaten as food) will be a combination of soluble and insoluble fibers. There are some
exceptions, especially with some grain seeds and seed husks such as psyllium, which is very
high in soluble fibers.
Water-holding capacity, however, is not the only predictor of benefits when adding fiber to
the diet. Foods high in fiber are rich in other phytonutrients, some which are bound within
the matrix of the fiber itself. Certain fibers are also important foods for the healthy
microbial organisms in the gut and a class of these has been termed "prebiotics" for their
ability to stimulate probiotic bacterial growth (Bifidobacteria especially). In fact, looking
at other characteristics, such as viscosity, susceptibility to fermentation, effect on
digestive enzymes, bile acid binding capacity and anion exchange capacity must be added to
its water-holding capacity to fully gauge the therapeutic benefits of individual fibers. Even
the shape of certain fibers is likely to be important as inert plastic in the "shape" of
flakes improved bowel transit time, while plastic as small granules had no effect (23).
As we have seen, the decreased intake of fiber as a function of modern food practices is
suggested by many to be the leading cause of idiopathic constipation. While this has been
empirically shown in adults for more than a century, this has recently been researched
specifically in children. In one study in Brazil, children with chronic constipation
typically ingested 20-30% less fiber than age and gender matched controls with normal bowel
habits (24). In a larger sample group of children in Greece, dietary fiber alone was
independently and inversely correlated with chronic constipation, despite the child's age or
age of onset of constipation (25). Furthermore, a study done in the U.S., showed that
constipated children were consuming less than one fourth of the age+5 recommended intake even
though they had been instructed "to eat a high-fiber diet" (26). It seems that in children,
as well as adults, increasing dietary fiber is a difficult lifestyle change that many simply
decline to make. The use of dietary fiber in patients in elderly care facilities, where less
individual control over diet is practiced, has also shown to decrease laxative use and
increase bowel frequency (27). This has also been the case in children with severe
developmental disabilities (28). Please see bulk laxative section below for more research on
the use of fiber as a therapeutic agent.
The role of dietary fiber from food is vital for maintaining balanced blood sugar levels,
especially in type 1 and type II diabetics. The mechanism is thought to be related with
fiber's (mostly soluble fiber) ability to slow glucose absorption from the small intestines
and reduce postprandial blood glucose levels. In a study published by the New England Journal
of Medicine in 2000, type II diabetic patients were placed on two different diets; each for 6
weeks (29). Each diet was identical with the exception of dietary fiber; one provided 24
grams of fiber (8 soluble, 16
insoluble) and the other provided 50 grams of fiber (25 soluble, 25
insoluble) per day. The additional fiber statistically lowered mean daily blood glucose,
daily urine glucose excretion, insulin concentration, triglycerides and VLDL cholesterol. In
a report comparing type I diabetic patients consuming less than 20 grams of fiber with those
consuming more than 30 grams of fiber per day, a significant decrease in blood glucose,
glycosylated hemoglobin, as well as number of hypoglycemic events was seen in patients taking
more fiber (30). These data suggest that it would be wise to advise all diabetic patients as
well as those with Syndrome X/metabolic syndrome, which may account for as many as 1/5 the
adult U.S. population (31), to increase dietary fiber, particularly soluble fiber (32).
Click on image
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Table 1 Fiber content of selected foods
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The role of water in constipation
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It would seem obvious that if constipation is often associated with hard, dry stools, water
intake would be beneficial for decreasing constipation. This is also one of the mechanisms
attributed to fibers; their ability to hold water in the stool, increasing stool size,
lubrication and stimulating peristaltic function. The function of water, in relation to fiber
intake was studied in a group of patients experiencing chronic constipation. One hundred and
seventeen patients were put on a standard diet providing 25 grams per day of dietary fiber.
One half of the group was given no instructions on water consumption while the other group
was instructed to drink 2 liters of mineral water per day. The second group drank, on
average, double what the first group consumed (2.1 vs. 1.1 liters). In both stool frequency
(p<0.001) and laxative use (p=<0.001) there was a statistical improvement in the group with
the higher intake of water (33). One study even suggests that carbonated water alone, as
opposed to tap water, may have additional benefits for relieving constipation, as well as
dyspepsia and gall bladder emptying (34). In contrast to these studied, in non-constipated
individuals, water seems to be important only when intake is very low, while additional water
intake was not shown to statistically increase stool frequency in these subjects (35,36).
While there is controversy over the amount of water that should be suggested for optimal
health, as well as multiple factors that influence hydration; it is probably safe to say that
most Americans do not drink enough water.
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Therapeutic Considerations
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For many, the diet, water and lifestyle options do not give adequate relief to their
constipation or do not fully satisfy their desire for regularity. Other natural options do
exist. But before discussing those, one more comment about lifestyle factors.
Regularity, by its very definition implies a cyclical reliability. If civilized life can be
accused of stripping the "regularity" from our foods, it can certainly be accused of
stripping the regularity from our life. The lack of regular eating, sleeping, working,
exercising and recreating is rampant in our culture. Meals are eaten in haste, and often at
different times each day. Hormones that are intended to be rhythmic and regular are irregular
in many due to chronic physical and emotional stress (for a complete discussion of this vital
topic see The Standard Vol. 3 No. 1- Adrenal Stress: diagnosis and treatment). Bowel
irregularity is a symptom of a greater irregularity in many individuals. Patients should be
encouraged to eat as many meals as possible sitting down in a relaxing environment with
individuals that promote wellbeing rather than stress. Regular sleep patterns should be
maintained as a norm, where this is possible for the patient. Intentional relaxation should
be practiced on a regular basis, and the patient should be instructed to never (within
reason) ignore the urge to defecate. It is difficult to expect one body system to maintain
regularity, while all the rest are in chaos.
There are several categories of ingredients for the treatment of constipation and nearly all
of them are natural ingredients. They include osmotic agents, bulking or hydrophilic
laxatives (primarily fibers), lubricating agents and stimulant laxatives.
Osmotic agents are essentially ions that, because of their amount or poor absorption, retain
water in the colon to maintain osmotic balance and provide for a laxative effect. The most
popular of these are poorly absorbed magnesium salts such as magnesium sulfate (Epsom salts)
and magnesium hydroxide (milk of magnesia). Some sugar alcohols such as sorbitol and mannitol
also have this same property, as does glycerin which is more often used as a suppository.
Ascorbic acid, in higher doses, also has the same effect on the stool. Made popular by Linus
Pauling, it is commonly known that high doses of ascorbic acid will induce "bowel
intolerance". This may have other benefits, but should be used for short-term treatment only,
except where the physician is familiar with high-dose vitamin C regimens.
These are the safest laxative for most individuals and should be considered first in the way
of treatment for idiopathic constipation. As was mentioned above, fiber from food sources
should be considered first, as the additional phytonutrients derived from these foods is
beneficial for disease prevention, although many "therapeutic fibers" have additional
benefits as well. Bulk fibers are also "dietary fibers" although they are usually in
concentrated forms and are primarily soluble fibers.
Flax seeds
Flax seeds should be considered food, but are included here because most individuals don't
consume flax except by intentional supplementation. Flax seeds have so many benefits it is
beyond the scope of this review to cover them all in depth but a few of the most important
will be mentioned.
Flax (Linum usitatissimum) is one of the most versatile plants for human use. The stem fibers
can be used for paper and linen and the seed is important for its omega-3 essential fatty
acid (alpha-linolenic acid), its fiber content (25% soluble) and its lignan content. It is
this combination that makes flax seeds one of the most versatile, although sometimes
forgotten, healthy foods. There are few people who would not benefit by adding flax, in one
or more forms, to their daily diet. Its ability to help in constipation is due to its
combined fiber/mucilage and oil which adds both bulk and lubrication to the stool. Its lignin
components are currently being investigated for their role in the prevention of breast
cancer, prostate cancer, blood sugar dysregulation, lipid dysregulation and its potential
phytoestrogenic effects. Of course the oil from the flaxseeds has numerous benefits as well
(see The Standard Vol. 3 No. 2 for additional information on flaxseed oil). As flaxseeds
contain so much polyunsaturated oil, seeds are usually purchased and ground just prior to
use, although freshly ground flaxseeds can be purchased and kept refrigerated. Flaxseed oil
is typically sold in bottles or softgel capsules, while purified flax lignans are typically
found in powder, capsule or tablet products.
Psyllium Seed Husks
Psyllium (Plantago psyllium) or Ispaghula (Plantago ovata) is perhaps the most widely used
ingredient in natural bulk laxative, and for good reason. The husk powder is nearly all
soluble fiber (71% by weight) and it has extremely high water holding capacity. As a bulk
laxative it increases both stool frequency as well as stool weight.
The use of psyllium for the relief of constipation has been confirmed by randomized
controlled clinical trials as well. Several clinical trials have compared the use of psyllium
with other laxatives and have found it superior in almost all cases (37). In one such trial,
compared to the stool softener/laxative docusate sodium, patients on psyllium (5g b.i.d.) had
significantly more frequent bowel movements and increased stool water output in 2 weeks (38).
In addition, psyllium seeds have proven useful in relieving constipation in patients with
Parkinson's disease (39), maintaining remission in patient with ulcerative colitis (40), and
reducing the potential for gallbladder disease (41). Ironically, the water holding capacity
of psyllium that make it so effective in treating constipation, is also capable of
controlling both fecal incontinence and radiation induced diarrhea (42,43). The
bowel
regulating aspects of psyllium is just one aspect of its therapeutic use however.
The FDA has approved a health claim for lowered cardiovascular risk for foods containing
psyllium, along with beta-glucan from oats. The modest, but significant drop in both total
and LDL cholesterol is consistent in both short-term and long-term clinical trials (44,45,46). The ability to prevent the reabsorption of bile (made from cholesterol in the liver) is
one of the proposed mechanisms for its hypocholesterolemic effects; other mechanisms are
currently being investigated (47). While this hypocholesterolemic effect has been reported
with other soluble fibers, in a study comparing 10 different fibers, psyllium-fed rats had
the lowest serum and liver cholesterol levels (48).
One of the more recent focuses of psyllium research is on its ability to modulate the
glycemic response of foods and lipid and glucose lowering effects in type II diabetics. The
addition of 15 grams of psyllium fiber to white bread was able to decrease the serum glucose
(AUC-glucose) by 40% in type II diabetic patients (49). This same 15 gram dose (5 g t.i.d.,
taken before meals), significantly reduced plasma glucose, total and LDL cholesterol and
triglycerides while significantly increasing HDL cholesterol in 6 weeks. Similar results were
obtained when type II diabetic patients received similar doses (50) or when they consumed
only 5 grams twice per day (51). The postprandial glucose and insulin effects are also seen
in "healthy" non diabetic subjects (52). This simple treatment would likely have wide-ranging
application to the growing numbers of adults diagnosed with metabolic syndrome (Syndrome X).
The long-term safety of psyllium-containing supplements is extremely high, with the exception
of those individuals who are allergic to psyllium. These products, as with other bulk
laxatives should not be used by individuals with bowel obstructions or narrowing of the
esophagus or gastrointestinal tract. Psyllium is unlikely to cause reduction in vitamin or
mineral absorption (53,54), but may result in lowered absorption of supplemental
oils if
consumed with the fiber supplement (Fish oils, Flax, CoQ10, Vitamin E etc).
Glucomannan
Glucomannan is a highly viscous fiber derived commercially from the tuber root of
Amorphophallus konjac and is thus often called konjac-mannan in the literature. While the
body of research is smaller than with psyllium, glucomannan has much of the same potential.
As little as 3 grams per day was sufficient to statistically improve bowel movement frequency
in patients with chronic constipation (55); and increasing to 4 grams per day nearly doubled
the effect (56). Additionally, glucommannan was used safely and effectively in neurologically
impaired children with chronic constipation (57).
As one would expect, glucomannan has an impact on glucose and lipid parameters, especially in
patients with insulin resistance. In two related studies conducted at the University of
Toronto, Canada, glucomannan (8-13 grams per day) enriched biscuits were able to reduce
several cardiovascular risk factors (including a slight but significant reduction in systolic
blood
pressure) in patients with type II diabetes (58) and reduce a host of cardiovascular risk
factors in Syndrome X patients (59). These findings confirmed other research showing a 10%
drop in serum cholesterol, 7% drop in LDL-cholesterol, 23% drop in triglycerides and a 2.5%
drop in systolic blood pressure after 4 weeks of a 4 gram/day addition of glucomannan (60).
Other Fiber Supplement Ingredients
Many other soluble and insoluble fibers have been used as ingredients in foods and dietary
supplements. One of the more popular is guar gum, derived from the seed of the East Asian
plant Cyamopsis tetragonoloba. Used quite often in foods and beverages to add viscosity, it
has also been researched for its effects on insulin and blood lipids, with excellent success
(61,62,63,64),
although not so much for its effect on chronic constipation. Other
ingredients that one is likely to see in addition to those mentioned already
are: pectin (apple or citrus), wheat and oat bran (more common in foods), sugar-beet fiber,
fenugreek fiber, other gums (locust bean, karaya), celluloses, and fructoligosacharides
(FOS), each with varying levels of activities and published literature.
Botanical stimulant laxatives all generally contain a class of compounds referred to as
anthraquinone glycosides. Once ingested and activated by bacterial metabolism in the human
gut, these molecules promote water retention in the stool and stimulate increased peristalsis
in the large intestines.
Aloes
Aloes powder is the solid residue obtained by evaporating the liquid which drains from the
transversely cut leaves of Cape Aloes (Aloe ferox). The juice is usually concentrated by
boiling and solidifies upon cooling. It is characteristically dark-brown or greenish-brown.
It has a sour odor; the taste is bitter. Cape Aloes is found primarily on the Cape Horn of
South Africa where it can typically grow 6-10 feet tall. The best-characterized constituent
of the resin is aloin, one of the compounds in the family of anthraquinone glycosides. Other
similar quinones are also present. It is thought that aloin and similar derivatives are
converted into emodin-derivatives within the gastrointestinal tract and then these act as
purging laxatives (65-68) Aloes' effect is primarily caused by its influence on the motility
of the colon- an inhibition of stationary and stimulation of propulsive contractions. This
results in an accelerated intestinal passage and, because of the shortened contraction time,
a reduction in liquid absorption. In addition, stimulation of active chloride secretion
increases the water and electrolyte content in the stool. The preparations of aloes have been
in the U.S. Pharmacopoeia for over 100 years and it has a positive Commission E monograph
where it is listed for short-term constipation (69).
Despite aloes long-term use and reputation as the most potent natural laxative, cascara
sagrada and senna seem to be more popular because of the commonly held notion that aloes is
more often associated with side-effects such as cramping and nausea. This however has not
been the case when used in recent decades as a dietary supplement and likely is attributed to
information passed on from the use of preparations nearly a century ago (70).
Dosing aloes is different depending on the individual. The optimum dose is the smallest
dosage necessary to obtain a soft stool that passes without difficulty. For many individuals
this is one 250 mg capsule, although many may need 450 mg or more to obtain this effect.
Twenty four hours should be allowed to pass before the next dose is administered. Aloes
should not be used during pregnancy because of its uterine stimulant potential.
Anthroquinones are known to be secreted in breast milk of nursing mothers and this may purge
the child along with the mother. As with all stimulant laxatives, aloes should not be used
for longer than 2 weeks for most individuals.
Cascara sagrada and Senna
Considered "sacred" bark by those using it, cascara sagrada describes the small to medium-
sized tree Rhamnus purshiana (or Frangula purshiana). The primary use for cascara sagrada is
as a laxative, and has a long history of use among Native Americans and Western herbalists.
The German Commission E has a positive therapeutic monograph for laxative formulas with a
dose corresponding to 20-30 mg cascaroside A (or equivalent).
The dried leaflets and pods of Cassia senna (or related species), is most often referred to
medicinally as senna. These preparations contain the strong glycosides sennoside A and B. The
laxative preparation for senna has been used in medicinal teas in Europe, and powdered
extracts have become very popular in OTC medications here in the U.S. The typical dose is
0.6-2 grams (equivalent to 20-30 mg of sennoside B). Senna also has a positive Commission E
monograph for use in laxative formulations. Similar activities are found in Rhubarb root
preparations (Rheum officinale), although rhubarb is more commonly used in Asia.
Cautions with Stimulant Laxatives
The use of botanical stimulant laxatives should be considered only after diet, lifestyle, and
bulk laxatives have proven ineffective, and other causes have been ruled out. They are
contraindicated in cases of bowel obstruction, acute intestinal inflammation and abdominal
pain of unknown origin. They should not generally be used in children under 12 or in pregnant
or nursing women.
Overuse and abuse of laxatives is common. Potential dangers include electrolyte imbalance,
especially potassium deficiency which can lead to muscle weakness and heart function
disorders. This potassium imbalance can be further exacerbated by the use of thiazide
diuretics, corticoadrenal steroids or high doses of licorice root. Chronic use of
anthraquinone glycosides has been associated with an increased pigmentation of the intestinal
mucosa called pseudomelanosis coli. While this has been determined to be a benign condition,
it is diagnostic for laxative abuse and often alters the ability to diagnose other colon
diseases (71,72). While the available evidence is divided on whether chronic use of
stimulant laxatives will result in a condition of a "sluggish" colon, all attempts should be
made to move to bulk-forming laxatives and refrain from chronic use of stimulant laxatives.
Idiopathic constipation is commonly self-treated in the U.S. This does not mean, however,
that it is being treated effectively. Most patients will choose easy solutions, rather than
alter diet and lifestyle factors that will change their bowel habits. The information
presented here should help to show that most of the natural remedies that promote bowel
regularity, have numerous other health benefits as well.
·Whorton, James C. Inner Hygeine: Constipation and the pursuit of health in modern society. 2000 Oxford University
Press (New York)
·Yarnell, Eric. Naturopathic Gastroenterology. 2000 Naturopathic Medical Press. Version 1.3. 69113 Camp Polk Rd.
Sisters, OR 97750. To order this very useful reference email the author at: dryarnell@earthlink.net
·Mills S and Bone K. Principles and Practice of Phytotherapy: Modern Herbal Medicine. 2000 Churchill Livingstone
Edinburgh, UK
- Kellog, JH, The Itinerary of a Breakfast (Battle Creek, MI: Modern Medicine,
1918) Quoted from Inner Hygiene. See above.
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the general population: a prospective study.
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- Meshkinpour H, Selod S, Movahedi H, Nami N, James N, Wilson A. Effects of
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personal communications of the mild nature of cape aloes compared to other laxatives.
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